H 7187Health Insurance

Insurance - Benefit Determination and Utilization Review Act

This bill prohibits retrospective insurance denials and removes prior authorization requirements for certain addiction treatment medications starting in 2027.

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Introduced Jan 21, 2026Committee House Health & Human Services

Plain-English Summary

This legislation updates regulations for health insurance companies and Medicaid providers in Rhode Island. It prohibits insurers from denying coverage for a medical service after the fact if they had previously approved it, unless the approval was based on false information. Additionally, starting January 1, 2027, the bill prevents insurers from requiring prior authorization for specific medications used to treat opioid and alcohol use disorders, such as Methadone and Buprenorphine. Finally, it mandates that Medicaid managed care organizations use specific state-approved criteria when determining if a medical service is necessary.

For younger readers

This law helps people get the medicine they need to get better. Sometimes, insurance companies say "yes" to paying for a doctor visit but then change their mind later. This law says if they say "yes" first, they can't change it to "no" later. Also, for people who are sick from addiction to drugs or alcohol, the law says they can get their medicine right away without waiting for the insurance company to check it first. This makes sure sick people get help faster.

Who & Where It Applies

Impacted groups

Health insurance companiesMedicaid recipientsPatients with opioid or alcohol use disorderMedical providersPharmacists

Impacted communities

All

Constitutional & Fiscal Check

None Likely

Estimated cost

None

Estimated revenue

None

Bill Analysis

Both viewpoints

For Progressives

Removes administrative barriers to accessing life-saving medication for opioid and alcohol use disorders, directly assisting vulnerable populations and addressing the overdose crisis.
Protects patients from financial harm by preventing insurance companies from unfairly reversing coverage decisions after care has already been delivered.
Standardizes medical necessity criteria for Medicaid managed care, ensuring that low-income residents receive consistent and fair evaluations for healthcare services.
The prohibition on prior authorization for addiction medications does not take effect until 2027, leaving patients facing potential barriers to care for several more years.
The exception allowing retrospective denial for "materially inaccurate" information could be exploited by insurers to deny claims based on minor technical errors.
The scope of the prior authorization ban is limited to specific addiction medications and does not extend to other critical mental health treatments that face similar barriers.

For Conservatives

Enforces contract integrity by preventing insurers from reneging on pre-approved agreements, ensuring business predictability for healthcare providers.
Streamlines the prescription process for specific medications, potentially reducing administrative overhead and paperwork for medical practitioners.
Standardizes Medicaid criteria across managed care organizations, which could reduce bureaucratic inconsistency and administrative waste within government-funded programs.
Interferes with the free market by dictating internal business processes and risk management strategies of private insurance companies regarding claim reviews.
Removing prior authorization reviews for specific drugs may lead to over-prescribing and increased healthcare costs that are ultimately passed down to consumers.
Centralizes power by mandating that private Medicaid organizations use state-selected criteria rather than their own efficiency standards to determine medical necessity.

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Full Bill Text

Changes to existing Rhode Island law · 16 additions

SECTION 1. Chapter 27-18.9 of the General Laws entitled "Benefit Determination and Utilization Review Act" is hereby amended by adding thereto the following section: 27-18.9-17. Utilization review decisions.

(a) A utilization review decision shall not retrospectively deny coverage for healthcare services provided to a covered person, when prior approval has been obtained from the insurer or its designee for those services, unless the approval was based upon fraudulent, materially inaccurate, or misrepresented information submitted by the covered person, authorized person, or the provider.

(b) For health benefit plans issued or renewed on or after January 1, 2027, an insurer shall not require or conduct a prospective or concurrent review for a prescription medicine:

(1) That is used in the treatment of alcohol or opioid use disorder;

(2) That contains Methadone, Buprenorphine or Naltrexone; or

(3) That was approved before January 1, 2027, by the United States Food and Drug Administration for the mitigation of opioid withdrawal symptoms.

(c) In conducting utilization reviews for Medicaid benefits, each Medicaid managed care organization shall use the medical necessity criteria selected by the Rhode Island division of insurance for making determinations of medical necessity and clinical appropriateness pursuant to the utilization review plan.

SECTION 2. This act shall take effect upon passage.